Trick or Treatment?:
Alternative Medicine on Trial

Simon Singh + Edzard Ernst

Singh and Ernst begin with the origins of evidence-based medicine,
covering the rejection of blood-letting, the discovery of a cure for
scurvy, and the statistical prowess of Florence Nightingale, among
other topics. Four chapters then evaluate the evidence for some of the
major alternative therapies: acupuncture, homeopathy, chiropractic,
and herbal medicine. These provide a history of the systems, as well
as of attempts to evaluate their success, and introduce critical tools
and concepts as they are needed.

There is borderline evidence that acupuncture may be useful for
pain and nausea, but no evidence of effectiveness for anything else.
Trials here are complicated by the difficulty of finding good placebos
for acupuncture treatment. This chapter introduces the concept of a
placebo, the idea of meta-analyses combining multiple studies, and the
Cochrane Collaboration, which is dedicated to high-quality systematic
reviews of the effectiveness of different medical treatments.

The chapter on homeopathy spends a lot of time on its history — it was
one of the many kooky endeavours favoured by Nazi science — and attempts,
in the face of pretty much all of modern physics and chemistry, to find
some kind of underlying mechanism for it. The actual evaluation of
homeopathy in high quality trials has been done and is quite clear-cut:
there is no evidence that any homeopathic treatment has any efficacy
for anything. Homeopathic remedies are very expensive placebos, which
may be dangerous where they displace treatments that actually work.

Chiropractic therapy has some efficacy for back pain, but not for
anything else. It can also, however, be quite dangerous, and should
only be used with care. Among other problems, chiropractic practitioners
massively over-treat patients, with investigations showing that most will
happily prescribe unnecessary X-rays and costly and sometimes dangerous
courses of treatment, even for completely healthy patients with transient
minor ailments.

There is good evidence for the efficacy of many herbal medicines. In
comparison to conventional medical drugs, however — and perhaps almost by
definition — they are poorly tested and regulated. Many are dangerous,
either directly, through interactions with other medicines, or through
contamination (high concentrations of heavy metals are common in Chinese
and Ayurvedic remedies), and many are used for inappropriate conditions.
Singh and Ernst provide a two page list of common remedies rating the
evidence for their effectiveness as "good", "poor", or "none", as well
as two pages summarising some of the risks of different herbal medicines;
they also provide suggestions for finding good quality suppliers.

The chapter on herbal medicines also looks at some of the reasons
people are attracted to alternative medicine ("natural", "traditional",
"holistic"), along with the ways practitioners both attack science
and pillage it for support, and some of the reasons both patients and
practitioners can be misled into thinking they work (such as regression
to the mean and confirmation bias). A final chapter considers a range
of other general issues: the culprits responsible for the popularity
of discredited and dangerous therapies, ways of improving conventional
medicine, and an approach to regulating alternative therapies better.

An appendix provides one page summaries of the evidence for thirty six
other alternative therapies, going alphabetically from Alexander Therapy
to Traditional Chinese Medicine.

Trick or Treatment? works well read through, but the chapter
structure is a little confusing. It doesn't really work to read just
the introduction and the chapter on homeopathy, for example, since the
key concept of a placebo is explained in the chapter on acupuncture.
And the chapter on herbal medicine contains unrelated material on tests
of prayer efficacy.

Trick or Treatment? will be a better book for most readers than
Bausell's Snake Oil Science, which emphasizes epistemology — abstract
problems of knowledge — more and history less, and which may be better
suited to doctors or other medical practitioners. For those who fall
somewhere between unthinking rejection and unthinking acceptance of
alternative medicine, Ernst (a professor of complementary medicine)
and Singh (a science writer) will be useful guides.